Co-existing biliary anomalies and anatomical variants in choledochal cyst

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Abstract
Background: Excision is the treatment of choice for choledochal cyst, and free bile drainage is essential to avoid ascending cholangitis. However, anastomosis between the relatively narrow common hepatic duct and bowel (conventional anastomosis) in case of type IV-A cyst, co-existing biliary anomalies and anatomical variations may cause ascending cholangitis resulting from insufficient biliary decompression. Methods: One hundred and four patients with choledochal cyst were treated by cyst excision. Conventional anastomosis was performed in 22 patients and hilar anastomosis in 82. Results: An anastomotic stricture developed in nine of the 22 conventional anastomosis cases and all required reoperation. Of the 82 hilar anastomosis cases, only one required reoperation for a primary stricture. Co-existing biliary anomalies and anatomical variants were seen in 26 patients: (1) primary stricture in 18; (2) aberrant posterior duct in two; (3) low confluence of the hepatic ducts in two; (4) aberrant hepatic artery in two; and (5) very small bile duct in two. All 26 patients underwent widening of the ductal lumen (ductoplasty) or additional procedures. Conclusion: Complete removal of the extrahepatic bile duct and a wide hilar anastomosis is essential to prevent ascending cholangitis. Ductoplasty or additional procedure can be performed only at the hilum.